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        .information-1
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</head>
<body>
    <div class="area1">医疗器械异常报告填写</div>
    <div class="area2">
    <span class="first-text">|</span>
    <span class="second-text">患者基本情况</span>
    <span class="third-text">（如无患者，请填写科室）</span>
    <form>
    <div>
        <table>
            <tr>
                <td class="td1" id="code">病历号： *</td>
                <td class="td2"><input style="width:540px;height: 33px;"></td>
            </tr>
            <tr>
                
                <td>病人信息：*</td>
                <td>
                    <div class="information-1">
                    <div>姓名&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>性别&nbsp;<select style="width: 137px;height: 33px;">
                        <option>男</option>
                        <option>女</option>
                    </select></div>
                    <div> 年龄&nbsp;<input style="width:139px;height: 33px;"></div>
                </div>
                </td>
                
            </tr>
            <tr>
                <td></td>
                <td><div class="information-2">
                    <div>民族&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>婚否&nbsp;<select style="width: 137px;height: 33px;">
                        <option>是</option>
                        <option>否</option>
                    </select></div>
                </div></td>
            </tr>
            <tr>
                
                <td>住院信息：*</td>
                <td>
                    <div class="information-1">
                    <div>科室&nbsp;<select style="width: 137px;height: 33px;">
                        <option>是</option>
                        <option>否</option>
                    </select>
                    </div>
                    <div>床号&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>费用&nbsp;<input style="width:139px;height: 33px;"></div>
                </div>
                </td>
                
            </tr>

            <tr>
                
                <td>住院时间：*</td>
                <td>
                    <div class="information-1">
                    <div>床号&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>费用&nbsp;<input style="width:139px;height: 33px;"></div>

                </div>
                </td>
                
            </tr>
    
            <tr>
                <td class="td1">住院天数： *</td>
                <td class="td2"><input style="width:540px;height: 33px;"></td>
            </tr>

            <tr>
                <td class="td1">临床诊断： *</td>
                <td class="td2"><input style="width:540px;height: 90px;"></td>
            </tr>
            <tr>
                <td class="td1">预期治疗疾病或作用： *</td>
                <td class="td2"><input style="width:540px;height: 90px;"></td>
            </tr>
        </table>
    </div>


    <!-- message2 -->

    <span class="first-text">|</span>
    <span class="second-text">事件基本情况</span>
    <div>
        <table>
            <tr>
                <td class="td1">报告来源:<span>*</span></td>
                <td class="td2">
                    <div class="radio">
                        <div><span class="radio1"></span><span>生产企业</span></div>
                        <div><span class="radio2"></span><span>个人</span></div>
                        <div><span class="radio1"></span><span>经营企业</span></div>
                        <div><span class="radio2"></span><span>使用单位</span></div>
                        <div><span class="radio1"></span><span>保密</span></div>

                        
                    </div>
            </tr>
            <tr>

            <tr>
                <td class="td1">是否匿名上报:<span>*</span> </td>
                <td class="td2">
                    <div class="radio">
                        <div><span class="radio1"></span><span>否</span></div>
                        <div><span class="radio2"></span><span>是</span></div>
                        
                    </div>
            </tr>
            <tr>
                
                <td>联系信息:</td>
                <td>
                    <div class="information-1">
                    <div>单位名称<input style="width:200px;height: 33px;"></div>
                    <div>联系地址<input style="width:200px;height: 33px;"></div>
                </div>
                </td>
                
            </tr>

            <tr>
                
                <td></td>
                <td>
                    <div class="information-1">
                    <div>邮政编码<input style="width:200px;height: 33px;"></div>
                    <div>联系电话<input style="width:200px;height: 33px;"></div>
                </div>
                </td>
                
            </tr>
            <tr>
                <td>事件发生日:</td>
                <td>
                    <input style="width:540px;height: 33px;">
                </td>
            </tr>

            <tr>
                <td>事件发生日期类型:</td>
                <td>
                    <input style="width:540px;height: 33px;">
                </td>
            </tr>

            <tr>
                <td>发生/知悉时间：:</td>
                <td>
                    <input style="width:540px;height: 33px;">
                </td>
            </tr>

            <tr>
                <td>事件发生的环境状态：:</td>
                <td>
                    <input style="width:540px;height: 33px;">
                </td>
            </tr>
            <tr>
                
                <td>给患者造成损害

                    的轻重程度：<span>*</span></td>
                <td>
                    <div class="radio-list1">
                        
                        <div>
                        <div>
                            <b>Ⅰ级：发生错误，造成患者死亡</b>
                        </div>
                        <span class="radio1"></span><span>
                            I级：导致患者死亡</span>
                        </div>

                        
                        <div>
                            <div>
                                <b>Ⅱ级：发生错误，且造成患者伤害</b>
                            </div>
                            <span class="radio1"></span><span>
                                I级：导致患者死亡</span>
                            </div>

                            <div>
                                <div>
                                    <b>Ⅲ级：发生错误，但未造成患者伤害</b>
                                </div>
                                <span class="radio1"></span><span>
                                    I级：导致患者死亡</span>
                                </div>

                                <div>
                                    <div>
                                        <b>Ⅳ级：错误未发生（错误隐患）</b>
                                    </div>
                                    <span class="radio1"></span><span>
                                        I级：导致患者死亡</span>
                                    </div>

                                 
                        
        
                    </div>
                 
                </td>
                
            </tr>

           
            <tr>
                <td class="td1">事件陈述<span> *</span></td>
                <td class="td2"><input style="width:540px;height: 33px;"></td>
            </tr>

            <tr>
                <td class="td1">备注</td>
                <td class="td2"><input style="width:540px;height: 200px;"></td>
            </tr>
            
        </table>
    </div>

   

    <!-- message4 -->

    <span class="first-text">|</span>
    <span class="second-text">报告基本情况</span>

    <div>
        <table>
            
            <tr>
                
                <td class="td1">病人信息：*</td>
                <td class="td2">
                    <div class="information-1">
                    <div>姓名&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>科室&nbsp;<select style="width: 137px;height: 33px;">
                        <option>男</option>
                        <option>女</option>
                    </select></div>
                    <div>职称&nbsp;<select style="width: 137px;height: 33px;">
                        <option>男</option>
                        <option>女</option>
                    </select></div>
                </div>
                </td>
                
            </tr>
            <tr>
                <td>联系信息：</td>
                <td><div class="information-2">
                    <div>民族&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>职业<span>*</span>
                        </div>
                         <div><span class="radio1"></span><span>生产企业</span></div>
                    <div><span class="radio2"></span><span>个人</span></div>
                    <div><span class="radio1"></span><span>经营企业</span></div>
                    </div>
                </div></td>
            </tr>

            <tr>
                <td></td>
                <td><div class="information-2">
                    <div>电子邮箱&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>签名&nbsp;<input style="width:140px;height: 33px;"></div>
                </div></td>
            </tr>
            <tr>
                
                <td>单位信息：*</td>
                <td><div class="information-2">
                    <div>单位名称&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>联系人&nbsp;<input style="width:140px;height: 33px;"></div>
                </div></td>
            </tr>

            <tr>
                <td></td>
                <td><div class="information-2">
                    <div>电话&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<input style="width:140px;height: 33px;"></div>
                    <div>报告日期<input style="width:140px;height: 33px;" ></div>
                </div></td>
            </tr>

            <tr>
                <td></td>
                <td><div class="button-style1">
                    <button style="width:200px;height:33px">确定提交</button>
                    <button style="width:200px;height:33px">暂存事件</button>
                </div></td>
            </tr>
            
        </table>
    </div>
</form>


    

</body>
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